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In December 2013, the Indian Supreme Court upheld Section 377 of the Indian Penal Code recriminalizing homosexuality in the country. The months since the judgement have been a time of uncertainty for the LGBT community about what lies ahead. The recent general elections saw political parties taking various positions on LGBT rights which resulted in heated debates in the media. Just last week in a surprise move, the new Health Minister spoke in support of gay rights. Through all this, the curative petition challenging the Supreme Court judgement is waiting to be heard.

The reaction from the LGBT community has ranged from anger and anguish to action inspiring the formation of new queer collectives and new projects responding to the needs of the community. The environment is a mixture of mistrust and determination, from watching one’s back to stepping up the tempo. This week, the International AIDS Conference is meeting in Melbourne, Australia to understand and discuss, among other issues, the HIV response for the communities of men who have sex with men and transgenders. Alliance India will be highlighting our “207 against 377” campaign that brings together the 207 organisations implementing Pehchan to fight Section 377.

As activists, community groups, and AIDS organizations come together to discuss important health and social issues facing sexual and gender minorities, it’s time to pause and take a hard look at what Section 377 means. It’s a law which oppresses LGBT communities for sure, but it is also an impediment to the realisation of basic human rights in the world’s largest democracy. Doing away with this law will influence other struggles against social injustice in a vastly complex country where people are oppressed not only because of their sexual orientation, but also their caste, class, religion and gender. Reading down 377 will be a victory for every citizen of India and for every human being across the world.

Shaleen Rakesh is a gay rights activist and was instrumental in filing the Section 377 petition on behalf of Naz Foundation (India) Trust in 2001. Shaleen manages the ‘207 against 377’ campaign atIndia HIV/AIDS Alliance, where he also serves as Director: Technical Support. The campaign brings together the 207 organizations implementing thePehchanprogramme on a common platform to undertake advocacy at national, state and district levels to protest against the 11thDecember 2013 Supreme Court judgment upholding constitutional validity of Section 377 of the Indian Penal Code thereby recriminalizing same-sex sexual behaviour.

Every two years, researchers, implementers, policy makers, and community activists come together at the International AIDS Conference to take stock of the pandemic: Where are we now? Where have we been? Where are we heading? Discoveries are heralded and strategies dissected. There are always more questions than answers, but there is one question that needs to be answered at AIDS 2014 and beyond: Do we count?

Do the lives of men who have sex with men, people who inject drugs, sex workers, transgenders and even people living with HIV — especially those from these key affected populations — really count? On a basic level, the answer must be a resounding and unequivocal “YES!” Every human life counts. Every life has equal value. Yet, while an affirmative chorus may echo in the halls of the conference, easy rhetoric will not be enough.

Data analysis by UNAIDS indicates that as many as half of all new HIV infections globally occur in key populations. This should come as no surprise. The disproportional concentration of the virus in these groups is hardly news, shaping the trajectory of the epidemic and driving the complex stigma that still defines HIV/AIDS.

Though we are frequently reminded that we are in the era of evidence-based public health, data-driven decision-making, and performance-based metrics, the evidence on HIV vulnerability in key populations is routinely ignored. We aren’t even counted in many places. Surveillance fails to find us. Not surprisingly, funding for HIV services responsive to our needs remains slight.

There can be no doubt about the sincerity or good intentions of the guidelines’ authors, and this document has the potential to influence policy and practice globally. Yet questions persist in the willingness of institutions — governments, donors, development agencies and civil society — to embrace their fundamental responsibility to the health of key populations and invest accordingly in a sustained and broad-based effort to end the unremitting toll of HIV and AIDS on our lives.

New technical guidelines and progressive policies can be applauded, but to make the difference intended, they must be applied. In order for them to be applied, investments must be targeted to fill these gaps and expanded to match the scale of our need. The proof of commitment will be in the expansion of funding invested in programming for key populations. Now is the time to prove we count.

Alliance India brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, we work through capacity building, knowledge sharing, technical support and advocacy. In collaboration with partners across India, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.

Women who use drugs are collectively failed by India’s HIV response! This systemic neglect involves government departments, civil society and the private sector. While government programs have done well to address issues of women’s empowerment and increase their access to education, health and social entitlements more broadly, there are virtually no initiatives that address the various specific needs of women who use drugs.

Out of the 120 hospital-based de-addiction centres run by the Government of India’s Department of Health and Family Welfare and over 400 NGO-run centres through the Ministry of Social Justice and Empowerment, none are focused on issues of women, and most have little experience in supporting women who use drugs. A few private facilities cater to these needs, but they are expensive and out of reach for most women.

While the Department of AIDS Control is now funding Targeted Interventions for HIV prevention among these women, they are limited to the north-eastern part of the country. Besides this, interventions are primarily designed for male drug users, although some of which have been able to successfully reach their female partners with services.

In our new film Out of the Shadows: Women Who Use Drugs in India activists and community members describe their challenges and their need for accessible, targeted, and quality harm reduction interventions to improve their health and protect their rights. Marginalized and unreached, these women are not well served by current interventions, and unsafe sexual behaviour and shared injecting equipment significantly increase their risk for HIV and hepatitis C infection. Exclusion, discrimination and violence further compound their vulnerability.

Women who use drugs need to emerge from the shadows, and programming in India can no longer afford to ignore them and the difficulties they face. There is a clear need for leadership and support to expand interventions for them by both government and civil society. We owe it to those women who are still in darkness and afraid to come out and live healthy and dignified lives.

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The author of this post, Simon W. Beddoe, is Advocacy Officer: Drug Use & Harm Reduction, at India HIV/AIDS Alliance in New Delhi.

With funding from European Union, the Asia Action on Harm Reduction project supports advocacy to increase access by people who inject drugs (PWID) in India to comprehensive harm reduction services and reduce stigma, discrimination and abuse towards this vulnerable population through engagement with PWID and local partners in Bihar, Haryana, Uttarakhand, Delhi and Manipur.

So much has been written about Avahan – by implementers, academics, and journalists – that to write more might be unnecessary. Many have reflected on the complexity of the programme and its ambition. What would it take to have an impact on the HIV epidemic in India’s highest burden states at a scale usually expected only of government? The learnings of Avahan are ample and thusly well documented. India’s fascination with Avahan’s donor surely was a story unto itself and told many times.

Yet, for me, the central contribution of Avahan is simple, and remarkably, it still remains radical today. Leveraging the prestige and resources of the Bill & Melinda Gates Foundation, Avahan focused its efforts on key populations, groups whose social marginalization previously all but ensured that their needs would not be adequately prioritized in spite of their disproportionate vulnerability to HIV.

Before Avahan arrived, India had already recognized that sex workers were an important driver of the country’s epidemic. The data told this story, and the government had a plan. Other key population groups like men who have sex with men and people who inject drugs were similarly targeted. Yet, capacity in the government to meet these challenges was limited. Apprehension about HIV was just part of the problem. How does a government effectively protect the health of groups that are criminalized and pushed to the margins of society?

What Avahan did – putting key populations first – should have been game-changing for the global AIDS response. How little the global AIDS response has actually changed now a decade later is testament to how difficult it is to break through the stigma and discrimination that define this disease. For all our talk in public health about evidence-based responses, what is done about AIDS still passes through a moral and political filter. Though we know we can find HIV concentrated in sex worker, MSM and drug using populations worldwide, we still don’t invest resources to match the relative scale of the epidemic in these groups.

Avahan showed it can be done. The Gates Foundation deserves great praise for its vision and resolve. The Government of India’s National AIDS Control Organisation (now, Department of AIDS Control) and the State AIDS Control Societies were essential collaborators, giving the programme the space it needed to show impact. Avahan’s implementing partners took the programme to the community level in six states across the country, with Alliance India working in Andhra Pradesh. Together, over the Avahan decade, we had the journey of a lifetime, empowering vulnerable communities and changing the trajectory of India’s epidemic.

AvahanIndia AIDS Initiative (2003-2014) was a focused prevention initiative funded by the Bill & Melinda Gates Foundation that worked in six states of India to reduce HIV transmission and lower the prevalence of sexually transmitted infections in vulnerable high-risk populations – female sex workers (FSWs), men who have sex with men (MSM), transgenders, people who inject drugs (PWID) – through prevention education and services, such as condom promotion, STI management, behaviour change communication, community mobilization, and advocacy. Alliance India was a state lead partner for Avahan in Andhra Pradesh (AP).

The fight against 377 will continue in India even as many countries adopt regressive laws.

Five years ago today – July 2, 2009 – was a historic day for India’s gay movement. On that day, the Delhi High Court decriminalised homosexuality. This ruling marked a sea change, a transformative moment when a history of intolerance was at last ended.

Though correct, the judgment was sadly impermanent, being overturned by the Indian Supreme Court last December, reinstating an archaic law from the British colonial era that criminalized homosexuality as “against the order of nature.” A month later, Nigerian President Goodluck Jonathan signed the controversial Same-Sex Marriage Prohibition Bill, which bans not only same-sex marriage, but also homosexual behavior, organisations that advocate for gay rights, and even gatherings of members of the LGBT community.

Current laws in both India and Nigeria disregard the basic rights of each country’s citizens. Bisi Alimi, the first Nigerian to come out on national television there, said, “The difference between India and Nigeria is that while in India, it’s the penal code regarding homosexual behaviour that has been reinstated, Nigeria has actually gone through a process of constitutional criminalisation of homosexuality and homosexual relationships.”

While the criminalisation of homosexuality in Nigeria is certainly more sweeping than India, these laws are not confined to simply policing private spaces. The law in India has been often used to justify harassment of sexual and gender minorities in public. India is also experiencing an uptick in cases of violence against the LGBT community, although most go unreported, and for the ones that make news, there is little justice. Nigerian rights activists are already documenting similar injustices and violence.

“The advent of this new law has brought about a system legitimising brutalities. We have seen an increase in witch hunting of LGBT people, accusing them based on assumption. Five people have been charged so far, and many awaiting trials,” Bisi adds.

Some have compared the hatred of homosexuality of Nigerians to their love for football, the only two issues on which the country stands united. A recent public poll in the country shows that 98% of Nigerians think homosexuality is wrong. This contrasts with India where, at least, the educated middle class shows some support for gay rights. A recent poll conducted among Hindustan Times readers showed 80% opposed criminalization of homosexuality.

LGBT activists in Nigeria, like most of their colleagues in Africa, operate in extremely hostile and challenging environments. They remain under-resourced and severely isolated. India’s LGBT movement has greater access to resources and more support, although even some queer rights activists still struggle to be “out.”

“Now with the law, provision of services to LGBT people – including HIV services – is illegal. That means charities doing this work will have to close, and many have started folding up already. This will not only affect HIV prevention services but also treatment. Many men who need antiretroviral therapy will not be able to access it easily, and if they do at all, it will have to be done underground,” says Bisi.

Despite differences in the nature and magnitude of the homophobia, the impact of these laws reaches beyond LGBT communities in both Nigeria and India, impeding the work of civil society, public health workers and human rights defenders. Above all, what is happening in Nigeria, India and unfortunately too many other countries is a severe blow to the momentum of the global LGBT movement and is a huge cause of concern for human rights around the world.

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The author of this post is Shaleen Rakesh, a gay rights activist and was instrumental in filing the Section 377 petition on behalf of Naz Foundation (India) Trust in 2001. Shaleen manages the ‘207 against 377’ campaign atIndia HIV/AIDS Alliance, where he also serves as Director: Technical Support. The campaign brings together the 207 organizations implementing thePehchan programme on a common platform to undertake advocacy at national, state and district levels to protest against the 11thDecember 2013 Supreme Court judgment upholding constitutional validity of Section 377 of the Indian Penal Code thereby recriminalizing same-sex sexual behaviour.

India HIV/AIDS Alliance (Alliance India) is a diverse partnership that brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, Alliance India works through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.

Harm reduction services need to be amplified and customised based on community needs.

Observed every year on 26th June, International Day Against Drug Abuse and Illicit Trafficking remains focused largely on protecting society from the evils of drugs. There is however a burning need to consider the situation of people who use drugs. To what extent are we as a society enabling drug users either to quit taking drugs or – failing that – to minimize the harmful consequences of their drug use? This is where ‘harm reduction’ comes into play.

In India, harm reduction has generally meant helping people who inject drugs (PWID) reduce the harmful consequences of their injecting practices – notably the risk of HIV infection. Harm reduction has been adopted as the official policy of Government of India, though there has been criticism about the manner in which it has been done. Under the National AIDS Control Programme, preventing HIV among PWID is accomplished by delivering a package of services to them that include, access to clean needles and syringes (Needle Syringe Exchange Programmes, or NSEP), Opioid Substitution Therapy (OST), peer-education for adopting safer behaviours, primary medical care and referral for other health-care needs. This package of interventions, collectively called ‘Targeted Interventions’ (TIs) is typically delivered by NGOs working with PWID. The NGOs are financially and technically supported by the Government, and it is estimated that more than 80% of estimated 186,000 PWID in India are covered by such TIs.

However, we need to consider the variations in the injecting patterns of PWID in a vast and heterogeneous country like India. PWID from north-east India would have very different needs as compared to PWID from say, Punjab, who would need different services as compared to PWID from, say, Kerala.

Indeed, nationwide research studies have been able to document the variations and similarities in the drug use patterns of PWID in different parts of India. One such study looked at behaviours and practices of about 1,000 PWID from 11 different states of India. Another soon to be released study, by the same author in collaboration with India HIV/AIDS Alliance, involved specifically interviewing PWID from four states – Bihar, Haryana¸ Jammu and Uttarakhand titled ‘Drug Use Patterns among Clients Receiving Services from Targeted Interventions for People Who Inject Drugs.’

Such studies reveal very important facts about the situation of PWID in India. One clear, unambiguous finding has been that across the country, the injecting pattern in India is characterized by injecting ‘opioid’ group of drugs. There may be variations in the choice of opioid drug injected by PWID – from D-propoxyphene or pure heroin in the north-eastern states, to buprenorphine or pentazocine or street heroin (‘brown sugar’ or ‘smack’) in other states of the country. But in medical terms, almost all the PWID can be diagnosed as having suffering from ‘opioid dependence disorder,’ and intervention strategies must take this fact into account.

Another issue of concern which emerges from this available data is the progression and continuation of risky practices by PWID. On an average a typical person who injects drugs in this country begins his/her drug use career by using legal and common substance like tobacco or alcohol in the early teen years. By late teen years, he/she begins using illegal drugs, though through a non-injecting route (orally or through smoking). It is only after spending about five to six years as a non-injecting drug user, he/she begins injecting the drugs – often under the persuasion and influence of his peers. Soon as he/she begins injecting, he/she starts sharing needles and syringes, putting himself/herself and his/her peers at the risk of HIV. And here comes the interesting part. Only after having spent about four to five years as a person who injects drugs does he/she begin receiving harm reduction services from the TI. Thus, for many crucial years in their drug use careers, PWIDs remain out of the network of any services. Clearly, we are not ‘catching them young’!

A Hypothetical time-line of Drug Use Career of a typical IDU in India Adopted from Ambekar (2012)

Our data also show that even after coming in contact of harm reduction services, a certain proportion of PWID continue to share their injections. In a nationwide study, almost a quarter of PWIDs reported sharing their injections in last three months, despite receiving services for an average of about two years.

Thus two crucial issues which emerge are (a) we are reaching the population quite late, when a behavioural pattern appears to have been well established putting them at risk; and (b) our services are probably not geared to ensure zero sharing of injections. No wonder then, that recent research studies show that there is practically no reduction in HIV or HBV or HCV infection among people who inject drugs, despite provision of harm reduction services.

Does this mean we need a course correction? Do we need to think of innovative approaches and alternate models of service delivery? Do we need to enhance and intensify the existing programmes? A combination of all of the above? Worth thinking about on this year’s International Day Against Drug Abuse and Illicit Trafficking which is also the Global Day of Action for the Support. Don’t Punish campaign which promotes the human rights of people who use drugs and advocates against the harms of criminalising drug use.

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The author of this Post, Dr. Atul Ambekar is Additional Professor of Psychiatry at the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi. He is also member of the Strategic Advisory Group to United Nations of HIV and IDU and a member of the Technical Resource Group on IDU for the Department of AIDS Control, Government of India. Views expressed are his own.

Alliance India brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, Alliance India works through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.

In 1983, Larry Kramer wrote an article for the New York Native filled with righteous anger, brilliant insight and, reading it now more than 30 years later, electric prophecy. It began, “If this article doesn’t scare the shit out of you, we’re in real trouble.” He proceeds to catalogue the inaction and sheer terror that defined the emerging epidemic.

Kramer recounts the failures of government officials, the medical establishment, researchers, the media, and the gay community itself. With prescient accuracy he connects disenfranchisement with vulnerability to HIV and describes the unrelenting stigma that even today shapes our still inadequate response to the epidemic. He is perceptive as he is relentless. His message: “we must fight to live.”

Kramer’s article was titled “1,112 and Counting.” After three decades, we’re still counting. More than 36 million people have died from AIDS and nearly as many are living with HIV. In India, roughly 150,000 people died from AIDS-related causes last year, ten times the number in the United States. For all our progress, the fight is not over.

Larry Kramer wrote “The Normal Heart” in 1985 during the grimmest and most uncertain days of the epidemic. No other play – no other work of art really – comes as close to capturing those times, and it resonates even today. A long time coming, the film version from HBO brings us back and in doing so reminds us what it takes to act up and fight back.

“The Normal Heart” aptly gets its title from a W.H. Auden poem “September 1, 1939” written as the world teetered on the brink of another epochal tragedy, World War II. What was true in 1939 was true in 1985 and remains true today:

Hunger allows no choice
To the citizen or the police;
We must love one another or die.

The AIDS epidemic has reached across the world in ways that perhaps only Larry Kramer would have imagined in those early days, and there is still no choice.

Alliance India brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, Alliance India works through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.